Advocacy Update: 2/12/2014

Advocacy: Stop the Medicare Therapy Cap

How would you feel if your ability as a physical therapist to produce the best possible outcome for a patient was hindered by his or her limited Medicare coverage?  Would you feel satisfied discharging a patient because he or she has exhausted the annual Medicare coverage for physical therapy services and cannot afford to pay out-of-pocket, knowing that he or she has the potential to recover and progress further with your services?  Without a repeal of the Medicare therapy cap, Medicare beneficiaries and their physical therapists will be faced with these dilemmas.

As part of the Balanced Budget Act passed in 1997, the SGR (Sustainable Growth Rate) formula and Medicare therapy cap were created, placing Medicare beneficiaries on an annual financial limit for physical therapy and speech-language pathology services combined, with a separate limit for occupational services, for outpatient settings.  Currently, a $1920 annual cap is placed on Medicare beneficiaries to be split between physical therapy and speech therapy services with an automatic exceptions process that can provide for additional coverage beyond the $1920 limit if the need for continued skilled services is documented.  A medical review is required once costs have reached $3700 to have coverage continue.  The cap on services is a strict annual financial limit on services and is not renewed for a new diagnosis.

On January 1, 2014, this exceptions process was extended until March 31, 2014 under the SGR Reform Act of 2013, giving time to Congress to develop a permanent solution to the therapy cap.  This past week new legislation was introduced to Congress, but the proposed SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015) does not address extensions to or a permanent repeal of the Medicare therapy cap, which could mean a firm cap without the possibility of an extension.  We have to advocate for our patients during this critical time by lobbying for inclusion of a repeal of the therapy cap on outpatient rehabilitation services in the final legislation passed.

Sign into the Legislative Action Center if an APTA member at or through the new PTaction app to email members of Congress today to express the need for a full repeal of the therapy cap and to ask for their support of the Medicare Access to Rehabilitation Services Act that would repeal the cap if passed.  If a non-APTA member, access the Patient Action Center to take action.

Information about the Medicare therapy cap gathered from

~Natalie Novak

February 12, 2014 |

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